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SHANNON PHARMACY
DSH450571 SHANNON MEDICAL CENTER
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Covered Entity Details
Entity Name
SHANNON MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH450571
Entity Address
120 EAST HARRIS AVENUE
SAN ANGELO, TX 76903
Medicare Provider Number
450571
Participating Start Date
7/1/2022
Last Recertification Date
8/30/2024
Pharmacy Details
Pharmacy Name
SHANNON PHARMACY
Pharmacy Address
122 S OAKES ST STE 100
SAN ANGELO, TX 76903
Pharmacy Comments
Contract Details
Approval Date
12/13/2016
Contract Begin Date
1/1/2017
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
2/28/2017
Covered Entity Terminated
Contacts
Covered Entity Signing Official
Staci Wetz, Chief Financial Officer
(325) 481-8416
Contract Pharmacy Representative
Krishna Vukoti, Pharmacist in Charge
(325) 655-1819
Signed By Date
12/13/2016
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